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Reflections on Safety is a monthly column presenting the insights of Tejal K. Gandhi, MD, MPH, CPPS, Chief Clinical and Safety Officer, Institute for Healthcare Improvement (IHI). Dr. Gandhi was president and CEO of the National Patient Safety Foundation prior to its merger with IHI in May 2017.

NPSF was founded in 1997, so this year marks our 20th as a leading voice for patient safety. It is not unusual while observing such a milestone to take time to reflect on where we’ve been and where we are headed.

Health care, and the patient safety field, have changed considerably over the past 20 years. At the beginning, NPSF was all about raising awareness, because people were not talking about preventable harm in health care back then. The first NPSF Patient Safety Congress was held in 2001 with the theme being, appropriately, “Let’s Talk.”

Since then, we have kept talking—and working—with many individuals and organizations committed to making health care safer. Among them have been government agencies, private foundations, professional societies, researchers, patients and patient advocates, industry, health care leaders, and frontline staff. NPSF has long held the position that everyone has a role to play in making health care safer. When we ask people about the Foundation’s place in the patient safety field, it is not unusual to hear the words “big tent,” an indication that NPSF has always been keen to invite those with diverse experiences and perspectives to share them in the interest of advancing our shared mission.

A notable change over the years has been a broadening of the definitions we use for patient safety. Initially, medical errors got the most attention and they were closely defined as adverse events or errors of omission or commission. More recently, patient safety has become the operative ambition for broad, organizational culture change and “systems of safety” that can prevent a wide range of harms, including those that are born of disrespect, poor communication, and insensitivity.

We’ve also seen wide acceptance of the fact that faulty systems, not bad people, are the cause of preventable harm in health care. Improving systems is an ongoing effort, because new therapies and technologies are introduced every day. Vigilance is required to avoid unintended consequences of any new tool.

Another advance has been the growing emphasis on the importance of joy, meaning, and workforce safety as a precondition to patient safety. We can never truly ensure the safety of patients if those who are caring for them are at risk of injury or emotional or psychological harm from disrespect or bullying.

Topping the agenda for our 20th year has been a push to address patient safety as a public health issue and to focus on culture and leadership as the foundation for safe care. These are challenging efforts, and we are living in challenging times for health care. Continued progress requires bold moves, innovation, and collaboration.

This is why, in this year of celebration, NPSF and the Institute for Healthcare Improvement (IHI) have chosen to merge. NPSF has provided critical thought leadership with the aim of establishing safety as a core value in health care, and IHI has demonstrated an ability to influence large-scale, global change.

Together, officially as of May 1, we believe our combined knowledge, skills, and resources will be more effective in helping leaders and frontline clinicians meet all of today’s challenges and, together, we intend to develop some fresh approaches to focus and energize the patient safety agenda.

We want to ensure that safety is a central part of every organization’s improvement strategy today, and that the safety of patients and the health care workforce becomes a core value of health care systems around the world.

I will have the privilege of leading the safety programs at IHI, and I hope you will stay engaged with us as we move the mission forward.

What do you think has been the biggest advance in patient safety over the past 20 years? What advances do you hope to see in the near future? Comment on this post below. Note: To comment, you must first register on the website. If you are already registered, you must log in to comment.

As many of you know, today marks the first business day of Patient Safety Awareness Week. This important week is a highlight of our United for Patient Safety Campaign and serves as dedicated time for raising awareness about patient safety among health professionals and the public.

With this in mind, today seems especially fitting to share the exciting news that NPSF and the Institute for Healthcare Improvement (IHI), are joining forces in an effort to accelerate progress in patient safety. The merger of our two organizations, which will be effective May 1, reflects a shared belief that patient safety is a public health issue and in need of a fresh and more robust approach. This bold move also reflects a strong commitment on the part of both organizations to making patient and workforce safety a core value in our health care institutions.

As we know, there is ample evidence to suggest that preventable harm in health care is a leading cause of death in the United States. In the Call to Action, NPSF calls on health care leaders and policymakers to initiate a coordinated public health response to improve patient safety and drive the collective work needed to ensure that patients and those who care for them are free from preventable harm.

Building on successful efforts to reduce health care associated infections and taking advantage of critical lessons learned, the Call to Action provides a new public health framework to guide collective efforts. The six-part framework, which was developed with significant insight and perspectives from the NPSF Board of Advisors and Board of Directors as well as senior officials at the US Centers for Disease Control and Prevention, identifies effective, replicable interventions that can be implemented across the health care system. It begins with defining the problem and setting national goals and involves improving coordination of activities across sectors and stakeholders.

In our current political climate, leadership at the federal level may be uncertain. But that doesn’t mean others cannot or should not take on a roll in playing a part. As a first step, organizations can demonstrate their commitment to advancing patient safety by supporting the Call to Action.

We at NPSF look forward to working more closely with IHI as well as our many other endorsers to advance the components of the Call to Action in the coming year. I hope you will review our framework, share it with your peers, and get involved with us in creating solutions.

Do you believe patient safety is a public health issue? Comment on this post below. Note: To comment, you must first register on the website. If you are already registered, you must log in to comment.

This week, NPSF announced a project we are undertaking in collaboration with CRICO, the Risk Management Foundation of the Harvard Medical Institutions, to identify best practices for managing referrals using electronic health records (EHRs).

Breakdowns in referral management are common and can result in missed or delayed diagnoses and other lapses in patient safety. Closing the loop on referrals is vitally important to achieving correct and timely diagnosis and treatment, and research suggests that EHRs have the potential to close these loops. Through this collaboration, we hope to outline best practices.

Take primary care, for example. A recent review of studies published from 1980 to 2014 finds that patient safety incidents are relatively common in primary care, with roughly 2 to 3 incidents per 100 consultations. Of these, an estimated 4% result in harm, with the most severe cases of harm commonly associated with diagnostic or prescribing errors.

Although considerable research is still needed into the causes of safety lapses in outpatient settings, we are also beginning to see resources developed that can help health care providers improve. In December, the Agency for Healthcare Research and Quality (AHRQ) began releasing resources as part of the Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families. This project is modeled on a similar guide for the hospital setting. Led by MedStar Health Research Institute, the guide for the primary care setting provides resources in four main areas:

Teach-Back: a technique for clearly communicating medical information to patients and families.

Be Prepared to Be Engaged: a toolkit for patients and families to use that helps them get ready for medical encounters.

Medication Management: a toolkit to help engage patients and caregivers in helping maintain accurate medication lists.

Warm Handoff: a practice wherein transfer of care from one clinician to another is done with the participation of the patient and family.

As AHRQ notes, patient engagement has been shown to contribute to improved safety and quality. NPSF has long advocated that patient and family engagement at all levels of the health care system is a vital component of safe care. What works best in a hospital setting can be very different than what works in primary care, however, and the challenges are different. These new materials from AHRQ are a terrific resource for those working in primary care, and they can help frame an incremental approach to improvement.

Another development comes from the World Health Organization (WHO). I had the privilege of serving as a reviewer last year on the WHO Technical Series on Safer Primary Care. Consisting of nine separate monographs on topics such as patient engagement, human factors, and transitions of care, this series delves into the scope and nature of harm in primary care settings.

Among its goals, the WHO project seeks to raise awareness among health professionals about the potential for safety lapses in primary care and to provide information about how to design and deliver safer care in that setting.

Raising awareness is a necessary first step in any improvement journey. The availability of these new resources is an encouraging sign that the patient safety pendulum is at last swinging to outpatient care.

What are your thoughts about improving the safety of primary care? Comment on this post below. Note: To comment, you must first register on the website. If you are already registered, you must log in to comment.

It snowed heavily in the Boston area this past weekend, resulting in challenging conditions for travelers. I watched one car try to make it up a hill during the worst part of the storm. Of course, driving in snow is hazardous, so we tend to slow down. But as the driver of that car discovered, slowing down can cause you to slip backward. Getting up a hill in difficult conditions requires that we maintain the right amount of momentum.

That’s what we are seeing in the patient safety field as well. As the field marks notable progress, now is the time to accelerate.

In December, the Agency for Healthcare Research and Quality (AHRQ) released the National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015. The agency estimates a 21% decline in hospital-acquired conditions (HACs)—such as pressure ulcers, adverse drug events, falls, and surgical site infections—since 2010. In real numbers, that amounts to 3.1 million fewer HACs than would have occurred had the 2010 rate remained unchanged. Moreover, AHRQ estimates that 125,000 fewer patients died as a result, and some $28 billion in health care costs was saved.

But most important, the agency acknowledges, as we all must, that we are nowhere near done when it comes to patient safety. AHRQ estimates that in 2015 there were 115 HACs per 1,000 discharges. That is a lot of patients who still experienced preventable harm. Moreover, the definition of harm is broadening now to include both physical and psychological harm, which makes the opportunities for improvement even greater.

Furthermore, we must acknowledge how much care is delivered outside of hospitals, and how little we know about ambulatory safety. Improving the safety of care across the continuum is one of the recommendations made in the NPSF report Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human. It is encouraging that entities like AHRQ and the World Health Organization are turning some attention to primary care. I will be writing more about those efforts in a future column.

The HAC reduction effort detailed in the AHRQ Scorecard was largely fueled by programs and rules made at the federal level, including Medicare payment penalties and the Partnership for Patients initiative introduced as part of the Affordable Care Act. Today, there is much uncertainty about the future of the health care system and the federal government’s role. At NPSF, we remain hopeful that the commitment to better quality and safety will remain, particularly as it has been shown to be fiscally beneficial.

In writing the preface to Free from Harm, Drs. Don Berwick and Kaveh Shojania, chairs of the expert panel that informed the report, note, “Today we must not let the many competing priorities in health care divert our attention from the important goal of preventing harm to patients. On the contrary—we need to keep our eyes on the road and step on the accelerator.”

As the New Year begins, that is what the National Patient Safety Foundation intends to do. We have a busy year ahead, and I hope you will join us however you are able.

What are your patient safety priorities for 2017? Comment on this post below. Note: To comment, you must first register on the website. If you are already registered, you must log in to comment.